Being poor can make you sick. Where you work, the air you breathe, the state of your housing, what you eat, your levels of stress and your vulnerability to crime, injury and discrimination all affect your health. These social determinants of health lie outside the reach of doctors and nurses.

In the early 1990s, Barry Zuckerman, the chief of pediatrics at Boston City Hospital (now Boston Medical Center), decided he was tired of seeing kids cycling back into the hospital again and again — asthmatic kids who never got better because of the mold in their houses, infants with breathing problems because their apartments were unheated. He’d write letters to the landlord, who ignored them, said Megan Sandel, who was an intern there at the time. Then at a cocktail party, someone listening to his complaints asked Zuckerman: What does the law say?

Zuckerman thought it was an important question. In 1993, he established the Family Advocacy Program with three lawyers to prod landlords, secure government benefits families were entitled to and fight with Medicaid, insurance companies, schools and other bureaucracies.

There were few medical-legal partnerships until about five or 10 years ago, but now 231 health care institutions have them, according to the National Center for Medical-Legal Partnership. The largest is New York’s LegalHealth, which works in about 20 New York hospitals and is expanding — it will soon have clinics in all 11 of the city’s public hospitals.

Medical-legal partnerships are growing in part because of increasing attention to social determinants of health.

Civil legal aid helps legal farmworkers get health insurance

DUNN, N.C. (AP) — Seasonal agricultural workers were just finishing a meal after a long day of planting sweet potato seeds when Julie Pittman pulled up to their camp.

Pittman, a paralegal with the Farmworker Unit of Legal Aid of North Carolina, worked to get their attention.

The health care law that passed in 2010 requires you to have health insurance, she said, speaking in Spanish. If you don’t get it, she said, you could be fined.

“Cuánto cuesta?” asked a worker, wanting to know the cost.

In the United States legally through the H-2A visa program, these farmworkers, like most American citizens and legal residents, must be insured. But reaching them is an uphill battle.

The majority come from Mexico to work in Florida, Georgia and North Carolina. The deadline for getting insurance starts when they enter the country. They have 60 days to learn about coinsurance and copayments, and decide whether to purchase a high- or low-deductible plan.

Alexis Guild, a migrant health policy analyst at Farmworker Justice, an advocacy group in Washington, D.C., said a yearslong partnership among various nonprofits and health centers in North Carolina has been working to enroll the workers.
***
Workers under the H-2A visa program are a small minority of the nation’s more than 2.4 million farmworkers, many of whom are in the country illegally and don’t have access to health insurance.

Their jobs are among the most dangerous, according to the Occupational Safety and Health Administration. Farmworkers face exposure to pesticides, and risk heat exhaustion and heatstroke.

Outside of emergencies, farmworkers can use community health centers, which receive federal funding to care for the poor and uninsured.

Dr. Eugene H. Maynard, of the Benson Area Medical Center, said many procedures can be done at his office, where fees are based on a sliding scale. But some require specialists, whose steep prices are out of the reach to most workers.

Often, Maynard said, he places workers on waiting lists for charity care, but these lists are so long that workers return to Mexico before seeing a specialist.